TY - JOUR

T1 - Liothyronine for hypothyroidism: A candidate for disinvestment or in need of further research?

T2 - A value of information analysis

AU - Hughes, Dyfrig

AU - Skiadas, Konstantinos

AU - Fitzsimmons, Deborah

AU - Anderson, Pippa

AU - Heald, Adrian

PY - 2021/12/3

Y1 - 2021/12/3

N2 - Objective: Medicines with limited evidence of effectiveness are prime candidates for disinvestment. However, investment in further research may be preferable to de-implementation, given that the absence of evidence is not evidence of absence, and research can inform formulary decisions. A case in point is liothyronine, which is sometimes prescribed to levothyroxine-treated patients who continue to experience hypothyroid symptoms. It is a putative low value medicine, associated with uncertainties in both clinical and cost effectiveness. The aim was to assess the cost-effectiveness of liothyronine in this context, and estimate the value of conducting further research.Design: Cost utility and value of information analyses.Setting: Primary care within the National Health Service in the UK.Participants: Fifty-four levothyroxine-treated patients with persistent symptoms of hypothyroidism.Interventions: Liothyronine plus levothyroxine versus levothyroxine alone.Primary and secondary outcome measures: Incremental cost per quality-adjusted life year (QALY) gained, and the expected monetary value of sample information.Results: 20/54 (37%) of patients who responded to the survey reported severe problems in carrying out usual activities of everyday living and 12/54 (22%) reported severe anxiety or depression symptoms. Mean (SD) utility was 0.53 (0.23). The differences in expected total, 10-year costs and QALYs between a treatment strategy of liothyronine/levothyroxine combination therapy, and levothyroxine alone, was £12,053 and 1.014, respectively. The incremental cost effectiveness ratio of £11,881 per QALY gained was sensitive to the price of liothyronine. The probability of liothyronine/levothyroxine combination therapy being cost effective at a threshold of £20,000 per QALY was 0.56. The value of reducing uncertainty in the efficacy of treatment was £3.64m per year in the UK.Conclusions: A definitive clinical trial to confirm clinical effectiveness may be preferable to immediate disinvestment, and would be justified given the value of the information gained far exceeds the cost.

AB - Objective: Medicines with limited evidence of effectiveness are prime candidates for disinvestment. However, investment in further research may be preferable to de-implementation, given that the absence of evidence is not evidence of absence, and research can inform formulary decisions. A case in point is liothyronine, which is sometimes prescribed to levothyroxine-treated patients who continue to experience hypothyroid symptoms. It is a putative low value medicine, associated with uncertainties in both clinical and cost effectiveness. The aim was to assess the cost-effectiveness of liothyronine in this context, and estimate the value of conducting further research.Design: Cost utility and value of information analyses.Setting: Primary care within the National Health Service in the UK.Participants: Fifty-four levothyroxine-treated patients with persistent symptoms of hypothyroidism.Interventions: Liothyronine plus levothyroxine versus levothyroxine alone.Primary and secondary outcome measures: Incremental cost per quality-adjusted life year (QALY) gained, and the expected monetary value of sample information.Results: 20/54 (37%) of patients who responded to the survey reported severe problems in carrying out usual activities of everyday living and 12/54 (22%) reported severe anxiety or depression symptoms. Mean (SD) utility was 0.53 (0.23). The differences in expected total, 10-year costs and QALYs between a treatment strategy of liothyronine/levothyroxine combination therapy, and levothyroxine alone, was £12,053 and 1.014, respectively. The incremental cost effectiveness ratio of £11,881 per QALY gained was sensitive to the price of liothyronine. The probability of liothyronine/levothyroxine combination therapy being cost effective at a threshold of £20,000 per QALY was 0.56. The value of reducing uncertainty in the efficacy of treatment was £3.64m per year in the UK.Conclusions: A definitive clinical trial to confirm clinical effectiveness may be preferable to immediate disinvestment, and would be justified given the value of the information gained far exceeds the cost.

U2 - 10.1136/bmjopen-2021-051702

DO - 10.1136/bmjopen-2021-051702

M3 - Article

VL - 11

JO - BMJ Open

JF - BMJ Open

SN - 2044-6055

IS - 12

M1 - e051702

ER -